Nursing standards to support the electronic health record.

Quality and low cost health care that is free of medical mistakes requires continuity of person-centric healthcare information across the life span and healthcare settings. Interoperable clinical information systems that rely on the use of multiple standards to support health information exchange and, in particular, nurse sensitive data, information, and knowledge are key components to support high quality, safe care. A 2004 Executive Order called for a National Health Information Network and the widespread adoption of electronic health records (EHRs) by 2014. While there are numerous standards influencing the exchange of health data, the primary focus of this article is to synthesize the state-of-the-art in nursing standardized terminologies to support the development, exchange, and communication of nursing data. Research exemplars are described for information systems to support nursing practice using standardized terminologies and secondary use of standardized nursing data from EHRs for knowledge development.

[1]  Debra J. Konicek,et al.  Nursing Interventions Classification in Systematized Nomenclature of Medicine Clinical Terms: A Cross-Mapping Validation , 2007, Computers, informatics, nursing : CIN.

[2]  S. Hyun,et al.  Cross-mapping the ICNP with NANDA, HHCC, Omaha System and NIC for unified nursing language system development. International Classification for Nursing Practice. International Council of Nurses. North American Nursing Diagnosis Association. Home Health Care Classification. Nursing Interventions Clas , 2002, International nursing review.

[3]  Gloria Bulechek,et al.  Describing use of nursing interventions for three groups of patients. , 2005, Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing.

[4]  M. Matsuki.  [Nursing diagnosis. 2]. , 1985, [Kango] Japanese journal of nursing.

[5]  A. Coenen,et al.  Using nursing diagnoses to explain utilization in a Community Nursing Center. , 1996, Research in nursing & health.

[6]  Suzanne Bakken,et al.  Informatics for Patient Safety: A Nursing Research Perspective , 2006, Annual Review of Nursing Research.

[7]  Robert A. Israel,et al.  International Classification of Diseases (ICD) , 2005 .

[8]  G. Raup,et al.  Computerized charting--an essential tool for survival. , 1995, Caring : National Association for Home Care magazine.

[9]  L. Everett,et al.  Cost of hospital care for elderly at risk of falling. , 2005, Nursing economic$.

[10]  J. Helberg.  Patients' status at home care discharge. , 1993, Image--the journal of nursing scholarship.

[11]  C. Delaney,et al.  Nursing Management Minimum Data Set (NMMDS). , 1997, The Journal of nursing administration.

[12]  C. Delaney,et al.  The Nursing Management Minimum Data Set. , 1997, Applied nursing research : ANR.

[13]  Elizabeth Yakel,et al.  HANDS: A revitalized technology supported care planning method to improve nursing handoffs. , 2006, Studies in health technology and informatics.

[14]  G. Keenan,et al.  Standardized Nursing Terminologies Can Transform Practice , 2008, The Journal of nursing administration.

[15]  R. Hughes.  Patient Safety and Quality: An Evidence-Based Handbook for Nurses , 2008 .

[16]  D. Reed,et al.  Assessing the reliability, validity, and sensitivity of nursing outcomes classification in home care settings. , 2003 .

[17]  Elizabeth Yakel,et al.  Promoting Safe Nursing Care by Bringing Visibility to the Disciplinary Aspects of Interdisciplinary Care , 2005, AMIA.

[18]  Karen S. Martin,et al.  The Omaha system : a key to practice, documentation, and information management , 2005 .

[19]  Dochterman,et al.  Nursing interventions classification (NIC). , 1992, Medinfo. MEDINFO.

[20]  Myonghwa Park,et al.  Using a Nursing Minimum Data Set with older patients with dementia in an acute care setting. , 2004, Journal of advanced nursing.

[21]  B L Westra,et al.  The Nursing Minimum Data Set: abstraction tool for standardized, comparable, essential data. , 1991, American journal of public health.

[22]  K. Marek,et al.  Nursing diagnoses and home care nursing utilization. , 1996, Public health nursing.

[23]  K. Martin,et al.  Home health clients: characteristics, outcomes of care, and nursing interventions. , 1993, American journal of public health.

[24]  Elizabeth Yakel,et al.  Documentation and the Nurse Care Planning Process , 2008 .

[25]  S. Moorhead.  Nursing outcomes classification (NOC) , 2000 .

[26]  Virginia K. Saba,et al.  Clinical Care Classification (CCC) System Manual: A Guide to Nursing Documentation , 2006 .

[27]  Sharie Falan,et al.  Establishing competency in the use of North American Nursing Diagnosis Association, Nursing Outcomes Classification, and Nursing Interventions Classification terminology. , 2003, Journal of nursing measurement.

[28]  G. Keenan,et al.  Toward collecting a standardized nursing data set across the continuum: case of adult care nurse practitioner setting. , 2003, Outcomes management.

[29]  B. Westra,et al.  The Omaha System: Bridging home care and technology , 1999 .

[30]  Norma M. Lang,et al.  Identification of the nursing minimum data set , 1989 .

[31]  G. Budreau,et al.  Cost of care for seniors hospitalized for hip fracture and related procedures. , 2007, Nursing outlook.

[32]  E. Halloran,et al.  Exploring the DRG/nursing equation. , 1985, The American journal of nursing.

[33]  JULIA R. STOCKER,et al.  The HANDS Project: Studying and Refining the Automated Collection of a Cross-setting Clinical Data Set , 2002, Computers, informatics, nursing : CIN.

[34]  J J Warren,et al.  Toward comparable nursing data: American Nurses Association criteria for data sets, classification systems, and nomenclatures. , 2001, Computers in nursing.

[35]  C. Delaney,et al.  A Nursing Management Minimum Data Set: Significance and Development , 1992, The Journal of nursing administration.

[36]  Joanne A. McCloskey,et al.  Nursing Intervention Classification (NIC) , 1993 .

[37]  G. Keenan,et al.  Toward integrating a common nursing data set in home care to facilitate monitoring outcomes across settings. , 2003, Journal of nursing measurement.

[38]  D. Reed,et al.  Establishing the validity, reliability, and sensitivity of NOC in an adult care nurse practitioner setting. , 2003, Outcomes management.

[39]  Bonnie L Westra,et al.  Use of the Omaha System data to validate Medicare required outcomes in home care. , 2006, Journal of healthcare information management : JHIM.

[40]  B. Westra,et al.  Integrating the nursing management minimum data set into the logical observation identifier names and codes system. , 2008, AMIA ... Annual Symposium proceedings. AMIA Symposium.